AUTHORIZATION TO DISCLOSEOBTAIN HEALTH INFORMATION - HARTFORD HOSPITAL (ENGLISH), #571559 Hartford H 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your MR# and Date Completed at the top of the form. This helps in tracking your request.
3. Fill in your Patient Name and Date of Birth. Ensure accuracy as this information is crucial for identification.
4. Indicate whether you are authorizing Hartford Hospital to disclose or obtain health information by checking the appropriate box.
5. Complete the section with the name, department, facility, address, telephone number, and fax number of the entity receiving or sending information.
6. Select the Method of Disclosure by checking one or more options such as Mail, Verbal, Fax, etc.
7. Specify the Date(s) of Treatment and check all relevant types of information you wish to be disclosed.
8. State the purpose for this disclosure by checking one of the provided reasons or writing another reason if applicable.
9. Sign and date at the bottom of the form. If applicable, include your relationship to the patient.

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